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Congressional Care: Nurse Impact On Public Policy

How one nurse got mad, got elected, and is changing U.S. health care.

Government response can make or break public health efforts, something that has become clear during the novel coronavirus outbreak. Lauren Underwood MSN/MPH, RN, one of the few nurses—and the youngest Black woman—ever elected to Congress, spoke about the role nurses can play in informing evidence-based public health policy during a virtual May 2020 “Conversations with Nurse Leaders” event (sponsored by the Independence Foundation and hosted by Penn Nursing). What follows is a condensed and edited version of the conversation between Rep. Underwood (D-Ill.) and Margaret Bond Simon Dean of Penn Nursing Antonia M. Villarruel, PHD, RN, FAAN, who mentored Underwood while the Congresswoman was pursuing her BSN at the University of Michigan.

VILLARRUEL: You told me the first time we met (when you were an undergraduate) that your long-term goal was to get a presidential appointment to a major U.S. Health and Human Services (HHS) agency. You’ve done that, working under the Obama administration on public health emergencies and disasters, including shoring up inventory for the Strategic National Stockpile. How did you ultimately decide to run for Congress?

UNDERWOOD: To begin with, I knew I couldn’t stay in government when the next administration came in. I couldn’t help them repeal the Affordable Care Act (ACA), which I worked to implement before my appointment to HHS. So I moved home to Illinois. I found myself at my Congressman’s town hall, and he made a promise during a discussion about repealing the ACA—he would only support a proposal that let people with pre-existing conditions keep their health care coverage. Now, I’m a nurse with a pre-existing condition [ed., diagnosed with a heart condition in elementary school]—when he made that promise, I believed him. Then two weeks later he voted in the exact opposite way of what he promised. I got mad and decided, you know what, it’s on. I’m running.

A lot of nurses wonder how to go about getting involved with government policy. Tell me that story.

For me, it started with a policy class that changed my life—it made the connection between policy and politics and nursing and clinical practice. I also had access to professional development opportunities at the HHS, including women in politics leadership development programs that had an aspect of how to run for office. But for so many of us, there’s this idea that we’re not enough. We don’t know enough, haven’t done enough, don’t know the right people. We don’t have enough money or we’re not successful enough, you know. That is just so flawed. The American people are desperate for our leadership. I’m not saying go off and run for President tomorrow, even though we would support you if you did. What I’m saying is be involved and be engaged because you already have the skills to make a great difference and impact your communities right now. Think about things you can do concurrently with your career in nursing—we don’t have to make these hard decisions where we’re doing either/or. There’s no reason why you can’t be advocating, while at the same time talking to your legislator about the findings you’re seeing in practice, the findings you’re seeing in the community and the community you serve, and then offering specific recommendations. We bring such credibility to these conversations. And if your member of Congress or local legislators turn down outreach from you as a nurse, they should be ashamed of themselves.

You’ve talked about engagement with a wide variety of people. Are there other things our audience should be thinking about in cultivating leadership wherever it might be?

If we’re serious about transforming our health care system, if we really mean it when we say we want to lower health care costs, then we need more nurses at these decision-making tables. There are decision-making bodies at every level of government that can benefit from our collective expertise. Don’t self-select out of participating because a committee description doesn’t say they’re looking for a nurse. We bring such rich experience in our health care system, such deep knowledge of our communities, this incredible critical thinking and research ability, mastery of data and analysis. Those are all transferrable skills to public service, whether you advise the board of your county health department or decide to run for office.

“It started with a policy class that changed my life—it made the connection between policy and politics and nursing and clinical practice.”

And I’ve been encouraged that more graduate programs have been mandating that nurses take a policy course, understand how government works, etc. There’s more at stake than just the government funding available to your community. Literally every clinical decision you make is influenced by a policymaker in one way or another. What medications are available get determined by the Food and Drug Administration, the head of which is a political appointee. We don’t often think about the political ramifications of those types of things. But in all areas of our work we are being influenced by the political process, and we need to participate in it.

With your work on the ACA and in the HHS, you haven’t been a traditional nurse. I bet you’re not a traditional Congresswoman, either. You came at such an exciting time with such a wide influx of women and younger people. In your first days and weeks in office you talked about a number of hierarchies—how do you manage political change through this hierarchical component? Congress is very hierarchical.

It’s not easy—my new Congressional colleagues and I were walking into an institution that operates at the highest, most elite levels of power in this country, that at one time was only limited to wealthy white landowners. There are all these structures in place, historically and presently, that are not designed for young people, people of color, and the like. But we were there to get things done right now because this country was, and is, in an urgent time of need. It’s really important to use some of the core tools we walk in with—the value of relationships, not letting yourself be defined by others. So in order to be effective, I need to build relationships with my committee chairman, with the leaders of the House of Representatives, with my colleagues, and with individuals more senior than me on committees. Without these relationships, I will not be able to pass legislation and deliver for my community.

That sense of urgency that you have has led to good actions. I can see nursing or a nursing lens in everything that you’re doing.

President Trump has signed three pieces of my legislation so far—one to lower insulin costs, one to make sure kids are not dying in U.S. custody at the U.S-Mexico border, and one related to COVID-19. Things that just fit our moral code as nurses.

“In all areas of our work we are being influenced by the political process, and we need to participate in it.”

Black women are three to four times more likely to die as a result of childbirth in the United States—a statistic un-changed for my entire lifetime. I’m 33 years old, and there have been no national initiatives, no surgeon general support. And most of these are preventable deaths—because of the disparity, the U.S. leads the industrial world in maternal mortality. I just couldn’t let it stand, so I teamed up with a colleague—Dr. Alma Adams, a Congresswoman from North Carolina—to start the Black Maternal Health Caucus. I though it would just be us, but we launched with 50 members of the House of Representatives, including the House Majority Leader. Now we’re up to 100 bipartisan members and support in the Senate. Every Democratic presidential candidate over the last year has talked about this issue. We have introduced the Black Maternal Health Act of 2020, a suite of legislation that we’re calling the Momnibus, which addresses gaps in health care that impact maternal health. This includes expanding Medicaid to one year post-partum to connect moms with more screening, more access to treatment and care. It’s one of the most important things we can do to save lives—Medicaid pays for more than half of all births, and certainly for communities of color. Among other things, the Momnibus increases the perinatal workforce, as well. Women of color need to be able to have a choice in providers.

How might we help in bringing support to the Momnibus bills?

Take a look at the bills and see if you want to write your representative or your senator—ask them to support this legislation. I have a commitment to leading in a data-driven, evidence-based way, so the bills are grounded in the evidence and science. And we’re working with experts and academics across the country to make sure that, if the bills pass, they will be implemented as intended. We’re really open to feedback and ideas that nurses have, things they’re seeing in their practice, or things they’re seeing from their research and program evaluations or the like, that might be ideas that are ready to be scaled up and implemented nationwide. We know that the ideas don’t originate in Congress. We just want to lift up good ideas, disseminate them, put some little bit of money behind it so that people can have the resources they need to do the work and save lives.